Anaheim, CaliforniaOctober 22-25, 2014

VOLUNTEER APPLICATION FORM

Date: , 2014

Name:

First Middle Initial Last

Home Address:

Street City State Zip

Email Address: Date of Birth (mm/dd/yy)

Best Phone Number to Reach You: cell home business

Languages: ______( )Speak – conversational ( )Speak – Simultaneous Interpretation ( )Write ( )Read

What organization are you affiliated with?

___ Firefighters ___ Community Regional Medical Center___ College

___ UCI Irvine Health___Tyco___ Other

Do you have any limitations that would prevent you from lifting 25+ pounds? Yes no Walking? Yes NoStanding? Yes No . If yes, please explain:

Interests/Skills you can offer:______

Shifts vary in length. Please circle the times that apply to your availability. Please select only those times that you are available for the entire shift.

TUESDAY, OCTOBER 21, 2014 / 8:00AM – 12:00PM / 12:00PM - 4:00PM / 4:00PM – 6:00PM
WEDNESDAY, OCTOBER 22, 2014 / 7:00AM – 11:00AM / 11:00AM – 3:00PM / 3:00PM – 7:00PM / 5:00PM – 7:30PM / 7:00PM – 10:00PM
THURSDAY, OCTOBER 23, 2014 / 7:00AM – 11:00AM / 11:00AM – 3:00PM / 2:00PM - 5:30PM / 3:00PM-
7:00 PM
FRIDAY, OCTOBER 24, 2014 / 7:00AM – 11:00AM / 11:00AM – 3:00PM / 3:00PM – 7:00PM / 7:00PM-
10:15PM
SATURDAY, OCTOBER 25, 2014 / 7:00AM – 11:00AM / 11:00AM – 3:00PM / 2:00PM – 4:00PM / 3:00PM - 6:00PM
SUNDAY, OCTOBER 26, 2014 / 4:00AM - 8:00AM / 8:00AM - 12:00PM / 12:00PM – 4:00PM

A reminder of your scheduled date and time will be sent along with an Orientation Packet 4 weeks, but not less than 2 weeks, prior to the event.

☼Thanks for volunteering! Please fax, email, or mail this completed form to: 616-458-2831 Attn: Susan Wise; ; Phoenix Society address at the bottom of this form. Your personal information will be kept confidential and will not be distributed.

Phoenix World Burn Congress Volunteer Agreement

Please read and sign the below information that is used for Phoenix Society records and event insurance purposes:

Volunteer Liability Release

I, the undersigned volunteer, understand that I am not an employee, agent, subcontractor, or independent contractor of the Phoenix Society. I understand that the Phoenix Society will not provide me with compensation, insurance, worker’s compensation, or any other right or benefits, whether of an employee or otherwise. I will not exert any right to ownership of any products discovered or developed while providing volunteer services. In consideration of my voluntary involvement and participation with the Phoenix Society and any of their activities and events, I hereby acknowledge and agree for myself, my children, my heirs, assigns, executors, and administrators to assume all risks associated with these volunteer activities. Further, I knowingly release, waive, discharge and hold harmless the Phoenix Society, Inc., their officers, employees, agents, successors, volunteers, assigns, sponsors and affiliates from all liability, claims, demands, actions, and law suits for all injuries and damages of whatever type or kind sustained as a result of my involvement in such activities, whether or not resulting from negligence or otherwise. I hereby attest that my attendance and involvement in such activities is voluntary, that I am participating at my own risk, and that I have read the foregoing terms and conditions of this release.

Volunteer Attestation

I hereby confirm, represent, and warrant that I have never been convicted of or charged with a violent crime, child abuse or neglect, child pornography, child abduction, kidnapping, rape or any sexual offense, nor have I ever been ordered by a court to receive psychiatric or psychological treatment in connection therewith. I understand that in the event I am assigned to serve as a volunteer in the WBC Youth and Family program during scheduled program times, minor children under the age of 18 will be present. I hereby understand and agree to follow the guidelines of having no less than 2 adults present at all times during these sessions attended by minor children.

Confidentiality Agreement

I acknowledge that in the course of my volunteer activities I may have access to documents, data, or other information whether medical, financial, personal member information or otherwise, that is confidential and privileged from disclosure. I agree to hold in confidence and not disclose such confidential information to any person or entity. Upon conclusion of my volunteer assignment, I agree to continue to treat such information as private and privileged. I understand that failure to do so constitute a breach of confidentiality.

In the course of my activities as a volunteer I may have the opportunity to take personal photos or videos. No photos or video of any type may be taken of workshops, sessions, ordiscussion groups. Photos may be used for personal use only and may not be used for commerce, publication, or published works of any type without written permission by The Phoenix Society, Inc.

Background Check

I, the undersigned volunteer, authorize the Phoenix Society to receive information from the Secretary of State and any law enforcement agency, to the extent permitted by state and federal law, pertaining to any charges and/or convictions I may have had for violation of state and/or federal laws, including but not limited to traffic violations and convictions for crimes committed upon children.

I understand that such access is for the purpose of considering my application as a volunteer and that I expressly do not authorize the Phoenix Society to disseminate this information in any way to any other individual, group, organization or corporation.

I attest that I have read and voluntarily sign this agreement this ______day of ______, 2014.

Signature:______

The Phoenix Society for Burn Survivors offers equal opportunity to all, based upon individual merit and without regard to race, color, religion, national origin, sex, age, sexual orientation, height, weight, marital status or disability which, if needing accommodation, may be reasonably accommodated as required by law.

CONSENT AND RELEASE FOR

PHOTOGRAPHS, VIDEOTAPE, and TESTIMONIAL INFORMATION

The undersigned does hereby authorize the Phoenix Society, Inc. to use photographs, videotapes, and personal testimonial comments of: (print name) acquired during Phoenix World Burn Congress 2014 (Phoenix WBC). This includes photographs and video taken during any/all programs, events and activities associated with Phoenix World Burn Congress. This also includes comments offered during the Phoenix WBC program, written in Phoenix Society journals, written in evaluations, and written via any online or digital formats. This agreement does not include support groups and open mic sessions as those are considered confidential.

I understand that my photograph, video footage, comments or testimonials may be used in a wide variety of promotional materials including newsletters, flyers, posters, brochures, fundraising letters, donor correspondence, annual reports, websites, social networking sites and other print and digital communications. I permit the Phoenix Society to use and publish photographs, video footage and/or testimonial comments for publicity, advertising, educational, or any other lawful purposes to further their mission.

I also give permission for the Phoenix Society to release such testimonial comments, photographs and/or video to the news media, local Phoenix World Burn Congress host organizations, and any other individual/organization/entity it deems necessary. I also authorize the news media to videotape and/or conduct interviews for publication/airing to its viewers/listeners/readers. I hereby waive any privacy rights associated with such comments, testimonials, photography and video and any right I may have to inspect and/or approve the finished product or the advertising copy that may be used in connection therewith or the use to which it may be applied.

The undersigned hereby agrees to hold harmless the Phoenix Society, its officers, agents, and employees, from any liability and/or claims resulting from or arising in connection with the taking, publication and release of the comments, testimonials, photographs or videotapes of the undersigned pursuant to this Agreement.

Signature:Date______

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